Quality Assurance Nurse LTC
Position Purpose: The Clinical Quality Assurance RN will work in various capacities to review, monitor and train staff in the Long Term Care Department. Potentially working to review care management activities / records of the Care Management Teams and / or activities / clinical documentation submitted by the Intake Specialist. The Clinical Quality Assurance RN will review for to confirm accuracy and monitor timeliness in accordance with the Fidelis Care's policies and regulatory standards, ensuring adherence to departmental and regulatory data integrity standards and requirements including contractual obligations with State and Federal agencies such as New York State Department of Health (NYDOH), County Department of Health (CDOH), Local Department of Social Services and Center for Medicare & Medicaid Services (CMS). The Clinical Quality Assurance RN will also create, analyze, report and maintain metrics and processes in support of department and all relevant NYS programs and product lines. The Clinical Quality Assurance RN will ensure that their findings are summarized and reported to applicable management and take the specific focus / emphasis of relaying finding directly to staff and partnering with management to directly train and retrain staff. The Clinical Quality Assurance RN will take ownership to ensure staff members reach a level of competence in their assigned role and will devise individual plans in assisting staff in reaching the desired level of performance. The Clinical Quality Assurance RN will spend time in the field while reviewing Intake Specialist work and will actively coach and develop staff with real time training and real time feedback.
Review clinical documentation in order to ensure that all components of the Member's medical record are completed with quality standards and accuracy following the Company's policies and State regulations.
Maintain a tracking tool that will log unacceptable areas in the workflow and staff documentation performance indicating improvement is needed for discussion with management and/or at departmental team meetings.
Conduct monthly one-to-one sessions with Assessment nurses to provide re-education on best practices and clinical documentation.
Participate in educational and management meetings to improve clinical core measures and RN quality assessment documentations.
Assist with special projects as assigned to meet departmental goals and policies.
Act as a liaison between Field Nurses and Nurse Supervisors to improve clinical processes and workflow communication.
Assist with gathering data for routine reporting with other team members to be used for day-to-day purposes and at meetings.
Assist the Manager, as needed, to determine areas that require immediate remediation and assist Fidelis Care's employees to stay ahead of changing information while improving the quality and effectiveness of documentation being submitted.
Participate in training-related projects and identify training sessions that will support staff development as well as assist with the training of new employees.
Prepare various reports and correspondences as well as provide summary reports to highlight key findings for implementation of performance improvement plans.
Work with colleagues across business units such as Care Management and Regulatory Compliance to ensure that process and procedural changes are reflected in the clinical documentation of the Assessment Nurses' such as job aids and policies.
Education/Experience: BA/BS - Bachelors Degree or equivalent required. Knowledge of Department of Health (DOH) and Local Department of Social Services and Center for Medicare & Medicaid Services (CMS regulations). Working in a home care environment or as a staff nurse in an acute, sub-acute or long-term care (LTC) setting or managed long-term care plan (MLTCP); Geriatrics, Medical Surgical Nursing, Case Management or Discharge Planning. Certification courses or other higher education in nursing, healthcare administration, business, operations management or other related discipline. Proficiency with healthcare terminology such as ICD 10 codes, medical abbreviations, medications. Experience in medical records review, claims processing or utilization and case management in a clinical practice or managed care organization. Experience analyzing various types of data and processes in a versatile manner including ability to present findings and make recommendations. Microsoft Excel skills with the ability to edit, search, sort/filter, format/use styles, create tables, calculate data using functions and formulas and create/use PivotTables for analyzing data.
License/Certification: Active NY RN License. Bilingual language preferences: Spanish, Russian, French, Creole, Mandarin, Shanghainese, Suzho, Cantonese, Toishanese, Fujianese, Fukanese, Fuzhounese Hindi, Bengali, Urdu or Nepali.
State registration with the Uniform Assessment System (UAS) for long-term care in NY State is required to access for training, testing and system usage. Upon completion of UAS training, the State will administer testing online. If a passing score is not achieved, the State will allow the individual to retake the test once. The UAS access is a necessity for this position, so employment is contingent on acceptance and continued authorization by the State to have UAS access.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
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